Are Online Pharmacies Fueling the Prescription Drug Abuse Epidemic?

Are Online Pharmacies Fueling the Prescription Drug Abuse Epidemic?

The Ryan Haight Act of 2008 gave the DEA the power to prosecute and shut down illegal online pharmacies. So why are so many still in business?

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On the morning of February 12, 2001, Francine Haight found her 18 year old son, Ryan, lying lifeless in his bed. Francine, a nurse, tried to resuscitate her son but it was too late. Ryan was dead of a Vicodin overdose.

“I was in shock,” Francine recounts. “Just the night before, we had dinner together after he came home from work at a nearby retail store. He used my Jacuzzi tub because he said his back bothered him from lifting things at work. At midnight I had kissed him goodnight and he said ‘love you, Mom.’”

After asking Ryan’s friends about the drugs and finding out that he had purchased them on the Internet, Francine sent Ryan’s computer to the DEA. The DEA found that Ryan had purchased the Vicodin from an online pharmacy which had then delivered the drugs directly to the Haights’ home.

If you look in your spam folder, you will probably find an ad for an online pharmacy. The majority advertise Viagra and Cialis and maybe some cholesterol drugs; drugs that require prescriptions but are not controlled substances restricted by the federal government. If you dig deeper, however, you can very quickly find whatever you’re looking for.

I once tried to score on the Internet. Many years ago, mid-kick and desperate, I searched online classifieds, looking for hidden code or secret meanings in every post; I was sure I could find someone discreetly selling heroin or other strong opiates. Why wouldn’t a dealer exploit the new global access of the web? I followed a “Pain Relief, all kinds” to a trailer park in the valley. The woman who answered the door was disheveled and her place was stacked floor to ceiling with newspapers, electronics, clothing. “Do you have the money?” She asked. Turned out she didn’t have the dope, but if I gave her my money she would “make some calls.”

These days you no longer have to wait around for an unreliable dealer, forge prescriptions, doctor shop, or engage in some other hustle to score your dope. While the FBI goes after deep underground drug selling sites like Silk Road, illegal online pharmacies have sprung up on every virtual corner. All you have to do is visit a website, make your choices, give your credit card info, and you’re set with a month’s (or more) supply of Ambien, Xanax, Ritalin, or morphine.

Jennifer was addicted to Ambien. She was the kind of drug addict who would take a handful of pills, lose consciousness, and wake up on the sidewalk in the middle of the night half-dressed. Or she would walk into a favorite restaurant, sober, and find that she’d been 86’d because of some Ambien-induced behavior that she didn’t remember.

“I was getting them prescribed by three doctors with refills, but my tolerance was so high and my body needed them so I wouldn’t go into withdrawal.” Jennifer was constantly requesting early refills and she knew that her behavior was sending up red flags at the pharmacies, so last year she decided to try her luck online.

Jennifer did a search and clicked on the first online pharmacy that popped up. She placed her order and the pharmacy called her back to get her debit card info. There was no request for a prescription, no doctor’s consultation. It was as easy to order Ambien, a federally controlled schedule 4 drug, as it was to order aspirin. Jennifer’s problems getting early refills were over. “This pharmacy doesn’t care about when you order. If I ordered 200 pills on a Tuesday, I could order another 200 on that Friday. They didn’t care, they were all about the money.”

After Ryan’s death, Francine Haight found that there were hundreds of online pharmacies (as of 2013, more than 34,000) selling prescription drugs. These pharmacies were able to dispense federally controlled drugs because there was never any explicit law against it. Laws governing the distribution of controlled substances were written in the 1970s, when no one could have predicted that one day sales could be made over a computer network. Consequently the law included no explicit prohibition against online pharmacies prescribing and distributing controlled substances. If prosecutors wanted to convict, they had to rely on an implicit prohibition, and do some tricky maneuvering in order to prove that online pharmacists’ methods “fall outside the usual course of professional practice.” This argument was used successfully in Ryan Haight’s case, and the online pharmacist and associated doctor were sentenced to prison.

The Ryan Haight Act and the DEA

As a result of Ryan’s case, Congress passed the Ryan Haight Online Pharmacy Consumer Protection Act of 2008. The act went into effect in April of 2009 and states that “No controlled substance that is a prescription drug as determined under the Federal Food, Drug, and Cosmetic Act may be delivered, distributed, or dispensed by means of the Internet without a valid prescription.” “Valid” means that the person writing the prescription has had at least one in-person visit with the recipient of the prescription. Also, each online pharmacy is required to list, on its homepage, the name of the affiliated pharmacist, his or her licensing info, the full name and address and phone number of the pharmacy, and a certification that the pharmacy is licensed to deliver controlled substances through the Internet.

Shortly after the Ryan Haight Act was made law, the DEA announced that the online pharmacy problem was close to being solved. According to a senior DEA official, “The Ryan Haight Act has pretty much eliminated the online business in the United States [and] the DEA hasn’t found a large number of foreign sites selling controlled substances to the U.S." In 2010, the DEA’s pharmaceutical investigations chief said that “(t)he Internet is not as big of a problem as we all think it is…especially dealing with controlled substances.” He added that he thought that the illegal pharmacies that were still in business were probably selling fake and counterfeit drugs. He went on to claim that the lack of any prosecutions (there have since been a couple of successful prosecutions, but they are drops in an ocean of illegal online pharmacies) under the Ryan Haight Act was due to the law having a successful deterrent effect.

Online pharmacies are interested in turning a profit by ensuring repeat customers. Selling fake drugs defeats that purpose unless the fake can consistently mimic the real drug well enough that the customer keeps coming back for more. The competition between rogue pharmacies is fierce; they operate like street dealers, offering specials and bulk discounts to regular customers. Their job is to keep you addicted so they can keep raking in profits. Whether the drug is counterfeit or genuine shouldn’t matter to the DEA anyway: the Haight Act prohibits the unrestricted selling of drugs that even claim to be controlled substances. Whether they are counterfeit or not is irrelevant.

Lisa placed her first online pharmacy order in 2009, the same year that the Ryan Haight Act went into effect. Like Jennifer, Lisa originally found her online pharmacy by doing a search. She placed an order then was contacted by phone the following day. “Jon” confirmed her order, told her she had VIP status which entitled her to certain benefits, and directed her to order from him going forward.

Lisa was a regular customer for two years. Her “personal account manager” was Jon for a while, then she started getting calls and emails from “Derrick” (sometimes Derrik), then “Lilly,” “David,” and “Chandra.” Each had a personal email address from Gmail or Hotmail and a U.S. phone number. Each account manager urged her to order only from him or her. In the beginning she would order in quantities of 180-200 which would last for a month or two.

“I was always paranoid to order too much because I thought they were going to think I was selling. I also didn’t want them to know I was a ‘drug addict.’ Ridiculous, right? They were thrilled to take my order.”

By 2012, two years after the DEA claimed it had successfully solved the rogue pharmacy problem, Lisa was spending about $4,000 a month on Ambien and Xanax. Lisa was never asked for a prescription, never directed to fill out a medical questionnaire, and never had to answer any questions about why she needed the medication.

Empirical data supports the anecdotal evidence provided by Jennifer and Lisa: According to a recent survey done by the National Association of Boards of Pharmacy on over 10,500 Internet pharmacy sites, 88% did not require prescriptions. An additional 9% were operating in violation of other pharmacy laws and practice standards, meaning that a remarkable 97% of online pharmacies are breaking federal law or otherwise compromising the security and safety of the consumer.

How can the DEA possibly claim that they have “pretty much eliminated the online business in the United States”?

The Ryan Haight Act is a U.S. law, and therefore can only be used by the DEA to prosecute and/or shut down online pharmacies operating in violation of the act in the U.S. Many, if not most, online pharmacies operate overseas. Both Jennifer and Lisa received their packages from Pakistan or India, or occasionally from the U.K. The DEA claims it cannot use the Haight Law to prosecute, but that is incorrect. Since these pharmacies operate as websites, no one knows where the physical supply of drugs actually is. It could be in some guy’s garage in Pakistan, or in a warehouse in England. But the selling is happening via website, and in order to reach the huge U.S. market, the websites almost always need to use domain name registrars, payment processors, and shipping services in North America. In some cases, the website hosting company is within the U.S. Since all of the selling is facilitated by U.S. channels, the businesses are operating within the DEA’s domain and should be subject to federal prosecution. If the DEA will not or cannot prosecute for some reason, they could at least alert these processing companies that they are being used for illegal purposes, something they all expressly prohibit. Presumably a letter from the DEA would carry enough weight to get these services to stop dealing with the rogue pharmacies. The pharmacies would then find themselves without a website, payment processor, or shipping service to use for their North American customers.

It can be difficult to pin down a rogue pharmacy because of the nature of the Internet – sites can be taken down and put up within minutes, and domain names can be pointed to new URLs easily. Also, many rogue pharmacies use tricks where they only advertise non-controlled substances on their homepages but have other domain names which, when clicked on, “unlock” hidden parts of their websites. So although the homepage for catchynamepharmacy.com only shows ads for Viagra and Celebrex (non-controlled substances), if you access the site via a different, heavily-advertised site name (something like getphenfennow.com, for example), you will get taken to a separate, interior page which will sell you phentermine, a federally controlled substance.

So these pharmacies are sneaky, but in the course of writing this article I was able to easily find more than one place to buy Ambien, Xanax, even morphine. If I can do it from my laptop in my living room, then surely the DEA has the ability and tools to do it. These rogue pharmacies are profiting at the expense, addiction, and sometimes lives of their customers. The DEA is the only federal agency that has the power to enforce the Ryan Haight Act and shut down these illegal businesses.

The DEA maintains a page about the Haight Act with a hotline for people to report suspicious pharmacies. I called the hotline and was given two menu items – one to report the abuse of controlled substances and one to report extortion scams. There was nothing about online pharmacies. After looking around more, I found a “Consumer Alert” with a link to a form which you can use to report a suspicious online pharmacy. The Consumer Alert also explains that buying controlled substances online without a valid prescription is a punishable offense, and that it is a felony to import drugs into the U.S. and ship to a non-DEA registrant. (All individuals and businesses that prescribe or dispense controlled substances must be registered with the DEA.)

So were Jennifer and Lisa committing federal crimes? Yes. Does it matter? No.

Once Lisa received a letter informing her that a package addressed to her had been seized by U.S. customs. If Lisa did not provide customs with proof of DEA registration, she would be in violation of the law. The letter included a form for Lisa to fill out and return. Alarmed, Lisa immediately called her current sales manager. He assured her that it was normal and she should ignore it, there was nothing to worry about and he would send out a replacement immediately. A few days later she received her regular shipment of Xanax and Ambien. This only happened once over the two years she was a regular customer.

Extortionists take advantage of the DEA's non-action

In a strange ironic twist, some criminals are taking advantage of the DEA’s lax attitude in going after the purchasers of these illegal prescriptions by pretending to be federal agents themselves. These con men call people who have, at some time in the past, purchased drugs online and tell them that they have broken the law and are at risk of going to prison. In order to avoid incarceration, the purchaser must pay a fine by wiring a sum of money to the “court.”

The DEA is very aware of this extortion scam, and it has gotten considerable media attention. In fact, based on the DEA homepage, the press release about the scam, and the message I received when I called the hotline, the DEA appears to be more concerned with this matter than it is with the issue of rogue pharmacies. Naturally, any impersonation of a federal agent is alarming and requires immediate action, but if the DEA was effectively policing and managing the rogue pharmacy issue, the opportunities for extortionists to implement this scam would be almost nil. Why not go after the root of the problem instead of making a huge deal about fixing one of its symptoms?

Operation Cyber Chase

Despite abundant evidence to the contrary, the DEA prides itself on a job well done “targeting rogue online pharmacies for prosecution and shutting down these illegal websites” and has a press release detailing its big takedown, “Operation Cyber Chase.” Operation Cyber Chase took place in 2005, before the Ryan Haight Act was implemented. We know, however, that even at that time there were thousands of unregulated pharmacies operating illegally. The result of the bust? 20 arrests in eight U.S. cities and four foreign countries. The press release explains that these criminals were using more than 200 websites to “illicitly distribute pharmaceutical controlled substances.” The DEA took great pride in Operation Cyber Chase: According to DEA Administrator Karen P. Tandy, “For too long the Internet has been an open medicine cabinet with cyber drug dealers illegally doling out a vast array of narcotics, amphetamines, and steroids. In this first major international enforcement action against online rogue pharmacies and their sources of supply, we’ve logged these traffickers off the Internet.” With the Ryan Haight Act providing even stronger tools for the DEA to use in their fight against these traffickers, why aren't there more press releases detailing successful investigations and prosecutions post-2005?

Chief Postal Inspector Lee R. Heath had high hopes at the time: "Operation Cyber Chase sends an instant message to ‘cybercriminals’ that the Internet is not their safehouse. Criminals, disguised as entrepreneurs, use the Internet to invade your home and push their poison. Whether the battle is on the street or on the Web, the outcome remains the same: Postal Inspectors will continue working with our law enforcement partners to bring offenders to justice.”

The prescription drug abuse epidemic

In 2011, the CDC reported that prescription painkiller overdoses have tripled over the past decade and SAMHSA reported a 430% spike in prescription painkiller addiction. In another recent study, The Partnership at DrugFree.org found that 36 million people, or one in six Americans, have gotten prescription medicine via the Internet without a prescription. Also, according to LegitScript, a company that monitors rogue pharmacies and provides a list of legitimate ones, the operators of these illegal pharmacies typically make five figures per month in commissions alone. Some surveys estimate that 10% of prescription drug abusers obtain their drugs through the Internet. Also in 2011, a study published by Jena and Dana Goldman, PH.D., showed a correlation between states with the greatest expansion in high-speed Internet access from 2000 – 2007 and the largest increase in prescription drug abuse treatment admissions. “For every 10 percent increase in high-speed Internet use during those years,” the study authors estimate, “admissions for prescription drug abuse increased 1 percent.”

While they were in the depths of their addiction, online pharmacies were like a godsend for Jennifer and Lisa. In recovery, however, they have found it difficult to escape the reach of their incessant marketing. Lisa, with over a year drug-free, continues to get email almost daily and phone calls from different numbers weekly. When I asked if she felt that it threatened her recovery, she told me that when she was at a weak place, she had given in: “I had a relapse two weeks out of treatment and 'Derrik' had called me that week. While on a prescribed refill of Xanax, I ordered thousands of dollars of pills from him. I tried to stop it the next day but couldn't. I had someone get rid of it when it was mailed to me. I was in sober living at the time. I immediately deleted all communication from him.” Two months later Lisa had a friend answer one of the calls. The friend told Derrik that Lisa had OD’d on prescription drugs purchased from an online pharmacy and asked if he would like to help in the investigation. Derrik hung up. A few days later the calls resumed. Lisa doesn’t answer, and blocks the numbers as they come in. Fortunately, she has reached a place in her recovery where she does not feel threatened. “Now, they are no longer a threat because [taking drugs is] not an option for me.”

Jennifer, who has been sober for over six months, gets calls daily, always from different phone numbers.

“I blocked all their numbers but they keep calling me from new ones.“

Jennifer has used the DEA reporting system to report the harassment multiple times but she has not gotten any response. She says she is considering changing her phone number, even though it will mean she’ll have to change her whole life around.

Prescription drug abuse usually starts with the doctor. If we have better safeguards in place and if doctors are educated more thoroughly on addiction, then fewer people will get addicted in the first place and be forced to look elsewhere for their fix when their prescriptions run out.

But more importantly, especially for those ex-addicts who used to get their drugs online, the DEA needs to go after these rogue pharmacies. Clearly the DEA’s data is flawed: the problem was not solved as a result of the Ryan Haight Act. The Haight Act did have an impact on DEA registrant pharmacies in the U.S. (such as the one that sold Ryan Haight the Vicodin that killed him). They will no longer dispense controlled substances without a valid prescription. But the vast majority of these rogue pharmacies went overseas (or were overseas to begin with) and so the DEA has been unable or unwilling to go after them. Sites like legitscript have pointed out ways to shut down these sites, but so far the DEA has not taken their advice.

In 2007, Judiciary Committee Chairman Sen. Patrick Leahy remarked that “Internet drug trafficking has presented another challenge for law enforcement. If drug dealers came into our neighborhoods selling these kinds of drugs, Americans would be up in arms.” It’s even more insidious than your neighborhood drug dealer; all you need is an Internet connection and a credit or debit card (and some sites sell their prescriptions COD so you don’t even need that).

Some progress

In June of last year, the FDA shut down 1,677 online pharmacies which were operating illegally. Also, most of these pharmacies rely heavily on search engine advertising. In 2011, Google settled with the federal government for $500 million for allowing these rogue pharmacies to buy sponsored ads in search engine results. Last year, UPS paid $40 million for shipping prescription drugs from known illegal pharmacies. Neither of these companies will do business with rogue pharmacies again. Google and Godaddy have partnered with American Express, eNom, MasterCard, Microsoft, Network Solutions, Neustar, PayPal, Visa, and Yahoo to create a nonprofit organization dedicated to taking down illegal online pharmacies. These admirable efforts are attempting to pick up the slack where the DEA has failed. Will it work?

Jennifer feels helpless. She is working hard to maintain her sobriety. In early sobriety, one of the best pieces of advice we give newcomers is to stay out of situations and places which you associate with drug use. But what if the place you associate with drug use won’t leave you alone? If your street dealer was harassing you, you could call the police. Jennifer has followed the DEA's instructions and reported the illegal activity, but no one has responded. Her pharmacy is still calling.

“All in all the whole thing really frustrates and upsets me, I feel like I’m their prey and they’re waiting for me to have a moment of weakness and say ‘what the hell, sure I’ll refill my order,’” Jennifer says. “I don’t even know if I have another sobriety in me. I would probably die.”

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